Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg. 2011;254:243-251. [PMID: 21597359 DOI: 10.1097/sla.0b013e31821f1564]

Axillary nodal disease burden is not associated with an elevated 21-gene recurrence score in post-menopausal women presenting with a clinically negative axilla

BACKGROUND

The predictive and prognostic value of the recurrence score (RS) has emphasized the importance of tumor biology and has reduced the prognostic implications of limited nodal burden in post-menopausal women with HR+/HER2-invasive breast cancer (IBC). It is unclear whether routine axillary staging has a continued role in the management of small, clinically node negative (cN0) HR+/HER2- IBC. We sought to estimate the association of RS with pN stage.

METHODS

Patients >50yo diagnosed with cN0, HR+/HER2- IBC (2015-2019) with an available RS were identified from the National Cancer Database. The clinicopathologic characteristics and rates of pN-stage (pN0, pN1, pN2/3) were compared for RS of ≤25 vs. >25.

RESULTS

The median patient age was 64.1 (IQR 58-69) and the majority (75%) of tumors displayed ductal histology. Most (81.6%) were cT1 on presentation and pT1 (74.7%) on final pathology. There were 130,568 (86.2%) with a RS ​≤ ​25 and 20,879 (13.8%) with a RS ​> ​25. On final pathology, 128,995 (85.2%) were pN0 and 21,991 (14.5%) pN1. Of the pN1, 2699 (12.3%) yielded a RS ​> ​25. There were 461 (0.3%) patients with pN2-pN3 disease. Of those, 57 (12.4%) had RS ​> ​25.

CONCLUSION

In our analysis, pN0 and pN1 tumors are biologically similar by gene expression assay in postmenopausal patients with similar proportions of high RS. These data support the notion that tumor biology examined via RS may have more prognostic and predictive value than metastatic dissemination to limited lymph nodes. These findings support the ongoing evaluation of routine axillary staging in postmenopausal patients with HR+/HER2- IBC.

Performance of MRI for standardized lymph nodes assessment in breast cancer: are we ready for Node-RADS?

OBJECTIVES

The Node-RADS score was recently introduced to offer a standardized assessment of lymph node invasion (LNI). We tested its diagnostic performance in accurately predicting LNI in breast cancer (BC) patients with magnetic resonance imaging. The study also explores the consistency of the score across three readers.

MATERIALS AND METHODS

A retrospective study was conducted on BC patients who underwent preoperative breast contrast-enhanced magnetic resonance imaging and lymph node dissection between January 2020 and January 2023. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated for different Node-RADS cut-off values. Pathologic results were considered the gold standard. The overall diagnostic performance was evaluated using receiver operating characteristic curves and the area under the curve (AUC). A logistic regression analysis was performed. Cohen's Kappa analysis was used for inter-reader agreement.

RESULTS

The final population includes 192 patients and a total of 1134 lymph nodes analyzed (372 metastatic and 762 benign). Increasing the Node-RADS cut-off values, specificity and PPV rose from 71.4% to 100% and 76.7% to 100%, respectively, for Reader 1, 69.4% to 100% and 74.6% to 100% for Reader 2, and from 64.3% to 100% and 72% to 100% for Reader 3. Node-RADS > 2 could be considered the best cut-off value due to its balanced performance. Node-RADS exhibited a similar AUC for the three readers (0.97, 0.93, and 0.93). An excellent inter-reader agreement was found (Kappa values between 0.71 and 0.83).

CONCLUSIONS

The Node-RADS score demonstrated moderate-to-high overall accuracy in identifying LNI in patients with BC, suggesting that the scoring system can aid in the identification of suspicious lymph nodes and facilitate appropriate treatment decisions.

CLINICAL RELEVANCE STATEMENT

Node-RADS > 2 can be considered the best cut-off for discriminating malignant nodes, suggesting that the scoring system can effectively help identify suspicious lymph nodes by staging the disease and providing a global standardized language for clear communication.

KEY POINTS

Axillary lymphadenopathies in breast cancer are crucial for determining the disease stage. Node-RADS was introduced to provide a standardized evaluation of breast cancer lymph nodes. RADS > 2 can be considered the best cut-off for discriminating malignant nodes.

Accuracy of sentinel lymph node biopsy in male breast cancer: Systematic review and meta-analysis

BACKGROUND

Sentinel lymph node biopsy (SLNB) is commonly used in the surgical management of male breast cancer. Contrary to female breast cancer, limited data exist about its performance in male breast cancer. The objective of this systematic review and meta-analysis was to evaluate the SLNB accuracy in male breast cancer.

METHODS

MEDLINE, EMBASE, Web of Science and The Cochrane Library were searched from January 1995 to April 2023 for studies evaluating the SLNB identification rate and false-negative rate in male breast cancer with negative preoperative axillary evaluation and primary surgery. For SLNB false-negative rate, the gold standard was the histology of axillary lymph node dissection (ALDN). Methodological quality was assessed by using the QUADAS-2 tool. Pooled estimates of the SLNB identification rate and false-negative rate were calculated. Heterogeneity of the pooled studies was evaluated using I2 index.

RESULTS

A total of 12 retrospective studies were included. The 12 studies that reported the SLNB identification rate gathered a total of 164 patients; the 5 studies that reported the SLNB false-negative rate gathered a total of 50 patients with a systematic ALND. The pooled estimate of the SLNB identification rate was 99.0%. The SLNB false-negative rates were 0% in the 5 included studies and consequently so as the pooled estimate of the false-negative rate with no heterogeneity.

CONCLUSION

SLNB for male breast cancer, following negative preoperative axillary assessment and primary surgery, appears feasible, consistent, and effective. Our research supports conducting immediate SLNB histological evaluation to facilitate prompt ALND in case of positive results.

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Navigate biopsy with ultrasound under augmented reality device: Towards higher system performance

PURPOSE

Biopsies play a crucial role in determining the classification and staging of tumors. Ultrasound is frequently used in this procedure to provide real-time anatomical information. Using augmented reality (AR), surgeons can visualize ultrasound data and spatial navigation information seamlessly integrated with real tissues. This innovation facilitates faster and more precise biopsy operations.

METHODS

We have developed an augmented reality biopsy navigation system characterized by low display latency and high accuracy. Ultrasound data is initially read by an image capture card and streamed to Unity via net communication. In Unity, navigation information is rendered and transmitted to the HoloLens 2 device using holographic remoting. Concurrently, a retro-reflective tool tracking method is implemented on the HoloLens 2, enabling the simultaneous tracking of the ultrasound probe and biopsy needle. Distinct navigation information is provided during in-plane and out-of-plane punctuation. To evaluate the effectiveness of our system, we conducted a study involving ten participants, assessing puncture accuracy and biopsy time in comparison to traditional methods.

RESULTS

Ultrasound image was streamed from the ultrasound device to augmented reality headset with 122.49±11.61ms latency, while only 16.22±11.25ms was taken after data acquisition from image capture card. Navigation accuracy reached 1.23±0.68mm in the image plane and 0.95±0.70mm outside the image plane, within a depth range of 200 millimeters. Remarkably, the utilization of our system led to 98% and 95% success rate in out-of-plane and in-plane biopsy, among ten participants with little ultrasound experience.

CONCLUSION

To sum up, this paper introduces an AR-based ultrasound biopsy navigation system characterized by high navigation accuracy and minimal latency. The system provides distinct visualization contents during in-plane and out-of-plane operations according to their different characteristics. Use case study in this paper proved that our system can help young surgeons perform biopsy faster and more accurately.

An ultrasound-based nomogram for predicting axillary node pathologic complete response after neoadjuvant chemotherapy in breast cancer: Modeling and external validation

INTRODUCTION

The staging and treatment of axillary nodes in breast cancer have become a focus of research. For breast cancer patients with fine-needle aspiration-or core needle biopsy-confirmed positive nodes, axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC) is still a standard treatment. However, some patients achieve an axillary pathologic complete response (pCR) after NAC. In this study, the authors sought to construct a model to predict axillary pCR in patients with positive axillary lymph nodes (cN+) breast cancer.

METHODS

Data from patients with pathologically proven cN+ breast cancer treated with NAC followed by ALND between January 2010 and April 2019 at the Peking University Cancer Hospital were reviewed. Axillary lymph node status was assessed using ultrasonography before and after NAC. The patient cohort was assigned to the construction and internal validation cohorts according to admission time. A nomogram was constructed based on the significant factors associated with axillary pCR. The predictive performance of the model was externally validated using data from Peking University First Hospital.

RESULTS

This study included 953 and 267 patients from Peking University Cancer Hospital and Peking University First Hospital, respectively. In the construction cohort, 39.7% (238 of 600) of patients achieved axillary pCR after NAC. The result of multivariate logistic regression analysis showed that tumor grade, clinical nodal response, NAC regimen, tumor pCR, lymphovascular invasion, and tumor biologic subtype were significant independent predictors of ypN0 (p < 0.05). The areas under the receiver operating characteristic curves for the construction, validation, and independent testing cohorts were 0.87 (95% confidence interval [CI], 0.84-0.90), 0.83 (95% CI, 0.79-0.87), and 0.84 (0.79-0.89), respectively.

CONCLUSIONS

A nomogram was constructed to predict the pCR of axillary lymph nodes after NAC for breast cancer. Validation of both the internal and external cohorts achieved good predictive performance, indicating that the model has preliminary clinical application prospects.

Predicting axillary metastasis in breast cancer using lymphatic contrast-enhanced ultrasound-guided fine-needle aspiration of one lymph node

OBJECTIVES

Fine-needle aspiration (FNA) is a microinvasive method to diagnose lymph nodes. This study aims to determine the capability of lymphatic contrast-enhanced ultrasound (LCEUS)-guided FNA in predicting the axillary metastasis with the target of one lymph node (LN) in patients with breast cancer.

METHODS

LCEUS was prospectively performed in 105 patients with breast cancer. The most suspicious LN was targeted based on the characters of LCEUS. FNA was performed in the LN, followed by localization using a guide wire. The detection of lymph cells and/or tumour cells was recognized as a puncture success. Cytologic diagnosis was compared with histologic diagnosis of wire-marked LN for diagnosing accuracy and compared with histologic diagnosis of axillary LNs for predicting accuracy.

RESULTS

LCEUS-guided FNA was performed in all 105 female patients who underwent axillary dissection. The puncture success rates were 74.3%, 91.4%, and 97.1% for three sequential groups (P = .010). In diagnosing LN metastasis, the sensitivity, specificity, and accuracy values of LCEUS-guided FNA were 89.7%, 100%, and 95.7%, respectively. In predicting axillary metastasis, the sensitivity, specificity, and accuracy values of LCEUS-guided FNA were 81.4%, 100%, and 91.3%, respectively.

CONCLUSIONS

The microinvasive LCEUS-guided FNA of one lymph node can be an accurate method and may help predict axillary metastasis in patients with breast cancer.

ADVANCES IN KNOWLEDGE

This study presented that LCEUS combined with FNA would be practical in clinic. The characters of LCEUS could indicate the suspicious LNs and promote the accuracy in predicting axillary metastasis.

Automated Versus Handheld Breast Ultrasound for Evaluating Axillary Lymph Nodes in Patients With Breast Cancer

OBJECTIVE

Automated breast ultrasound (ABUS) is a relevant imaging technique for early breast cancer diagnosis and is increasingly being used as a supplementary tool for mammography. This study compared the performance of ABUS and handheld ultrasound (HHUS) in detecting and characterizing the axillary lymph nodes (LNs) in patients with breast cancer.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of women with recently diagnosed early breast cancer (≤ T2) who underwent both ABUS and HHUS examinations for axilla (September 2017-May 2018). ABUS and HHUS findings were compared using pathological outcomes as reference standards. Diagnostic performance in predicting any axillary LN metastasis and heavy nodal-burden metastases (i.e., ≥ 3 LNs) was evaluated. The ABUS-HHUS agreement for visibility and US findings was calculated.

RESULTS

The study included 377 women (53.1 ± 11.1 years). Among 385 breast cancers in 377 patients, 101 had axillary LN metastases and 30 had heavy nodal burden metastases. ABUS identified benign-looking or suspicious axillary LNs (average, 1.4 ± 0.8) in 246 axillae (63.9%, 246/385). According to the per-breast analysis, the sensitivity, specificity, positive and negative predictive values, and accuracy of ABUS in predicting axillary LN metastases were 43.6% (44/101), 95.1% (270/284), 75.9% (44/58), 82.6% (270/327), and 81.6% (314/385), respectively. The corresponding results for HHUS were 41.6% (42/101), 95.1% (270/284), 75.0% (42/56), 82.1% (270/329), and 81.0% (312/385), respectively, which were not significantly different from those of ABUS (P ≥ 0.53). The performance results for heavy nodal-burden metastases were 70.0% (21/30), 89.6% (318/355), 36.2% (21/58), 97.3% (318/327), and 88.1% (339/385), respectively, for ABUS and 66.7% (20/30), 89.9% (319/355), 35.7% (20/56), 97.0% (319/329), and 88.1% (339/385), respectively, for HHUS, also not showing significant difference (P ≥ 0.57). The ABUS-HHUS agreement was 95.9% (236/246; Cohen's kappa = 0.883).

CONCLUSION

Although ABUS showed limited sensitivity in diagnosing axillary LN metastasis in early breast cancer, it was still useful as the performance was comparable to that of HHUS.

Is Axillary Staging Obsolete in Early Breast Cancer?

This article reviews the incidence of nodal metastases in early-stage breast cancer and the need for axillary staging to maintain local control in the axilla or to determine the need for adjuvant systemic therapy across the spectrum of patients with breast cancer, and reviews clinical trials addressing this question. At present, sentinel lymph node biopsy should be omitted in women age ≥70 years with cT1-2 N0, HR+/HER2- cancers. The importance of nodal status in selecting patients for radiotherapy remains the main reason for axillary staging in younger postmenopausal women with cT1-2N0, HR+/HER2- cancers.

Diagnostic Accuracy of Ultrasonography in Axillary Staging in Breast Cancer Patients

Background

Breast cancer is the most common malignancy affecting women all over the world and represents 7% of all cancer-related deaths in the UK. One of the most crucial elements in assessing a patient's prognosis and chance of survival with breast cancer is the condition of their axillary lymph nodes. Ultrasonography (US) is now used as a routine preoperative diagnostic tool for pretherapeutic axillary evaluation. The aim of the current study is to investigate the diagnostic accuracy of US in axillary staging in breast cancer patients.

Methods

We carried out this retrospective study for all invasive breast cancer patients who had surgery in addition to preoperative axillary staging using US during the period from January 2020 to February 2021. The final histology results were compared with the preoperative US findings to ascertain the sensitivity, specificity, positive predictive value, and negative predictive value of AUS in axillary staging.

Results

One hundred and twenty-eight patients were included in our study. The average age of diagnosis was 63.9 ± 12.3 years of age. We calculated sensitivity rate of 59.6%, specificity rate of 95.1%, positive predictive value of 87.5%, and negative predictive value of 80.2% with overall diagnostic accuracy of 82.2%.

Conclusion

Despite the important role of preoperative US in axillary staging in breast cancer patients; it failed to detect metastatic diseases in 14.8% of our patients. These findings necessitate the routine histological evaluation of the axilla for more accurate staging of the disease.

Future Directions in the Assessment of Axillary Lymph Nodes in Patients with Breast Cancer

Background and Objectives: Breast cancer (BC) is a leading cause of morbidity and mortality worldwide, and accurate assessment of axillary lymph nodes (ALNs) is crucial for patient management and outcomes. We aim to summarize the current state of ALN assessment techniques in BC and provide insights into future directions. Materials and Methods: This review discusses various imaging techniques used for ALN evaluation, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. It highlights advancements in these techniques and their potential to improve diagnostic accuracy. The review also examines landmark clinical trials that have influenced axillary management, such as the Z0011 trial and the IBCSG 23-01 trial. The role of artificial intelligence (AI), specifically deep learning algorithms, in improving ALN assessment is examined. Results: The review outlines the key findings of these trials, which demonstrated the feasibility of avoiding axillary lymph node dissection (ALND) in certain patient populations with low sentinel lymph node (SLN) burden. It also discusses ongoing trials, including the SOUND trial, which investigates the use of axillary ultrasound to identify patients who can safely avoid sentinel lymph node biopsy (SLNB). Furthermore, the potential of emerging techniques and the integration of AI in enhancing ALN assessment accuracy are presented. Conclusions: The review concludes that advancements in ALN assessment techniques have the potential to improve patient outcomes by reducing surgical complications while maintaining accurate disease staging. However, challenges such as standardization of imaging protocols and interpretation criteria need to be addressed. Future research should focus on large-scale clinical trials to validate emerging techniques and establish their efficacy and cost-effectiveness. Over-all, this review provides valuable insights into the current status and future directions of ALN assessment in BC, highlighting opportunities for improving patient care.

The effectiveness of ultrasound-guided core needle biopsy in detecting lymph node metastases in the axilla in patients with breast cancer: systematic review and meta-analysis

OBJECTIVE

This study aimed to perform a meta-analysis to investigate the diagnostic safety and accuracy of Ultrasound-Guided Core Needle Biopsy (US-CNB) Axillary Lymph Nodes (ALNs) region in patients with Breast Cancer (BC).

METHODS

The authors searched the electronic databases PubMed, Scopus, Embase, and Web of Science for clinical trials about US-CNB for the detection of ALNs in breast cancer patients. The authors extracted and pooled raw data from the included studies and performed statistical analyses using Meta-DiSc 1.4 and Review Manager 5.3 software. A random effects model was used to calculate the data. At the same time, data from the Ultrasound-guided Fine-Needle Aspiration (US-FNA) were introduced for comparison with the US-CNB. In addition, the subgroup was performed to explore the causes of heterogeneity. (PROSPERO ID: CRD42022369491).

RESULTS

In total, 18 articles with 2521 patients were assessed as meeting the study criteria. The overall sensitivity was 0.90 (95% CI [Confidence Interval], 0.87‒0.91; p = 0.00), the overall specificity was 0.99 (95% CI 0.98‒1.00; p = 0.62), the overall area under the curve (AUC) was 0.98. Next, in the comparison of US-CNB and US-FNA, US-CNB is better than US-FNA in the diagnosis of ALNs metastases. The sensitivity was 0.88 (95% CI 0.84‒0.91; p = 0.12) vs. 0.73 (95% CI 0.69‒0.76; p = 0.91), the specificity was 1.00 (95% CI 0.99‒1.00; p = 1.00) vs. 0.99 (95% CI 0.67‒0.74; p = 0.92), and the AUC was 0.99 vs. 0.98. Subgroup analysis showed that heterogeneity may be related to preoperative Neoadjuvant Chemotherapy (NAC) treatment, region, size of tumor diameter, and the number of punctures.

CONCLUSION

US-CNB has a satisfactory diagnostic performance with good specificity and sensitivity in the preoperative diagnosis of ALNs in BC patients.

A novel nomogram for the preoperative prediction of sentinel lymph node metastasis in breast cancer

BACKGROUND OR PURPOSE

A practical noninvasive method to identify sentinel lymph node (SLN) status in breast cancer patients, who had a suspicious axillary lymph node (ALN) at ultrasound (US), but a negative clinical physical examination is needed. To predict SLN metastasis using a nomogram based on US and biopsy-based pathological features, this retrospective study investigated associations between clinicopathological features and SLN status.

METHODS

Patients treated with SLN dissection at four centers were apportioned to training, internal, or external validation sets (n = 472, 175, and 81). Lymph node ultrasound and pathological characteristics were compared using chi-squared and t-tests. A nomogram predicting SLN metastasis was constructed using multivariate logistic regression models.

RESULTS

In the training set, statistically significant factors associated with SLN+ were as follows: histology type (p < 0.001); progesterone receptor (PR: p = 0.003); Her-2 status (p = 0.049); and ALN-US shape (p = 0.034), corticomedullary demarcation (CMD: p < 0.001), and blood flow (p = 0.001). With multivariate analysis, five independent variables (histological type, PR status, ALN-US shape, CMD, and blood flow) were integrated into the nomogram (C-statistic 0.714 [95% CI: 0.688-0.740]) and validated internally (0.816 [95% CI: 0.784-0.849]) and externally (0.942 [95% CI: 0.918-0.966]), with good predictive accuracy and clinical applicability.

CONCLUSION

This nomogram could be a direct and reliable tool for individual preoperative evaluation of SLN status, and therefore aids decisions concerning ALN dissection and adjuvant treatment.

[Radiologic evaluation of lymph nodes in cancer patients]

BACKGROUND

In solid tumors, the detection of locoregional lymph node metastases is of decisive importance not only for the prognosis but also for selecting the correct treatment. Various noninvasive imaging methods or, classically, lymph node dissection are available for this purpose.

OBJECTIVE

This article presents the general principles of noninvasive lymph node diagnostics and discusses the value of the clinically available imaging modalities, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). In addition, recent new technical developments of each modality are highlighted.

MATERIAL AND METHODS

Literature search and summary of the clinical and scientific experience of the authors.

RESULTS

The available imaging procedures are divided into (1) morphological (US, CT, MRI) and (2) functional modalities (PET, special MRI). The former capture structural lymph node parameters, such as size and shape, while the latter address properties that go beyond morphology (e.g. glucose metabolism). The high diagnostic accuracy required for future treatment algorithms will require a combination of both aspects.

DISCUSSION/CONCLUSION

Currently, none of the available modalities have sufficient accuracy to replace lymph node dissection in all oncological scenarios. One of the major challenges for interdisciplinary oncological research is to define the optimal interaction between imaging and lymph node dissection for different malignancies and tumor stages.

Surgical Management of the Axilla for Breast Cancer

This review discusses the contemporary surgical management of the axilla in patients with breast cancer. Surgical paradigms are highlighted by clinical nodal status at presentation and treatment approach, including upfront surgery and neoadjuvant systemic therapy settings. This review focuses on the increasing opportunities for de-escalating the extent of axillary surgery in the era of sentinel lymph node biopsy, while also reviewing the remaining indications for axillary clearance with axillary lymph node dissection.

Evaluating the Performance of Algorithms in Axillary Microwave Imaging towards Improved Breast Cancer Staging

Breast cancer is the most common and the fifth deadliest cancer worldwide. In more advanced stages of cancer, cancer cells metastasize through lymphatic and blood vessels. Currently there is no satisfactory neoadjuvant (i.e., preoperative) diagnosis to assess whether cancer has spread to neighboring Axillary Lymph Nodes (ALN). This paper addresses the use of radar Microwave Imaging (MWI) to detect and determine whether ALNs have been metastasized, presenting an analysis of the performance of different artifact removal and beamformer algorithms in distinct anatomical scenarios. We assess distinct axillary region models and the effect of varying the shape of the skin, muscle and subcutaneous adipose tissue layers on single ALN detection. We also study multiple ALN detection and contrast between healthy and metastasized ALNs. We propose a new beamformer algorithm denominated Channel-Ranked Delay-Multiply-And-Sum (CR-DMAS), which allows the successful detection of ALNs in order to achieve better Signal-to-Clutter Ratio, e.g., with the muscle layer up to 3.07 dB, a Signal-to-Mean Ratio of up to 20.78 dB and a Location Error of 1.58 mm. In multiple target detection, CR-DMAS outperformed other well established beamformers used in the context of breast MWI. Overall, this work provides new insights into the performance of algorithms in axillary MWI.

Nodal Positivity in Early-Stage Triple-Negative Breast Cancer: Implications for Preoperative Immunotherapy

BACKGROUND

Adding pembrolizumab to preoperative chemotherapy improves event-free survival in patients with early-stage triple-negative breast cancer (TNBC). However, owing to potential toxicities, the risk-benefit ratio of pembrolizumab must be considered. There is consensus that the addition of immunotherapy should be recommended in node-positive patients. This study is undertaken to determine nodal positivity rates in patients with TNBC presenting with cT1-2N0 disease undergoing upfront surgery and to evaluate the utility of axillary ultrasound and biopsy in the setting of a negative clinical examination.

PATIENTS AND METHODS

Patients with cT1-2N0 TNBC undergoing upfront surgery were identified from our institutional database (January 2016-February 2021; n = 343) and from the National Cancer Database (NCDB) (n = 46,015). Pathologic nodal status was determined. A second cohort of patients with cT1-T2 TNBC with a negative clinical examination was defined in our institutional database (n = 499), and utilization of axillary ultrasound was examined.

RESULTS

For patients undergoing upfront surgery, pathologically positive nodes were found in 14.6% patients of our institutional cohort: 9.4% cT1a/b, 14.9% cT1c, and 20.8% cT2 tumors. In the NCDB cohort, 13.7% patients were node positive: 4.9% cT1a/b, 11.4% cT1c, and 19.7% cT2 tumors. For patients with a normal clinical examination undergoing axillary ultrasound, 7.5% of cT1c and 8.7% of cT2 had suspicious nodes biopsied and confirmed positive for metastasis.

CONCLUSIONS

Pathologic node-positive disease is found in > 10 and 20% patients with cT1cN0 and cT2N0 TNBC, respectively. Axillary ultrasound can be used to identify patients presenting with a normal clinical examination for whom preoperative pembrolizumab should be considered.

The Value of Fine Needle Aspiration Biopsy in the Pre-Operative Assessment of the Axilla in Breast Cancer Patients

This paper reviews the role of fine needle aspiration biopsy (FNAB) in assessing the axilla prior to definitive surgery or neoadjuvant therapy in breast cancer patients. The radiological criteria for biopsy are discussed and pathological techniques and pitfalls illustrated. The sensitivity and specificity of the technique and the clinical utility are addressed, with particular reference to the current controversies in the management of the axilla in the light of the American College of Surgeons Oncology Group Z0011 trial results. The low morbidity procedure of FNAB is recommended when the radiological and clinical features suggest a high yield from the abnormal axillary nodes, with consideration of core biopsy if an expected positive result is not obtained or the circumstances require tissue for ancillary studies. In conclusion, FNAB of the axilla is a highly sensitive procedure which can offer further valuable information to assist in clinical decision making. The technique is of particular value in the setting of a large primary tumour size and multiple enlarged nodes. A summary flow chart is provided to facilitate pre-operative management of the axilla and to encourage a universal approach.

Accuracy and Utility of Preoperative Ultrasound-Guided Axillary Lymph Node Biopsy for Invasive Breast Cancer: A Systematic Review and Meta-Analysis

Background

With the acceleration of the pace of life and work, the incidence rate of invasive breast cancer is getting higher and higher, and early diagnosis is very important. This study screened and analyzed the published literature on ultrasound-guided biopsy of invasive breast cancer and obtained the accuracy and practicality of preoperative biopsy.

Method

The four databases were screened for the literature. There was no requirement for the start date of retrieval, and the deadline was July 2, 2022. Two researchers screened the literature, respectively, and included the literature on preoperative ultrasound-guided biopsy and intraoperative and postoperative pathological diagnosis of invasive breast cancer. The diagnostic data included in the literature were extracted and meta-analyzed with RevMan 5.4 software, and the bias risk map, forest map, and summary receiver operating characteristic curves (SROC) were drawn.

Results

The included 19 studies involved about 18668 patients with invasive breast cancer. The degree of bias of the included literature is low. The distribution range of true positive, false positive, true negative, and false negative in the forest map is large, which may be related to the large difference in the number of patients in each study. Most studies in the SROC curve are at the upper left, indicating that the accuracy of ultrasound-guided axillary biopsy is very high.

Conclusion

For invasive breast cancer, preoperative ultrasound-guided biopsy can accurately predict staging and grading of breast cancer, which has important reference value for surgery and follow-up treatment.

The role of pre-operative axillary ultrasound in assessment of axillary tumor burden in breast cancer patients: a systematic review and meta-analysis

BACKGROUND

Recent studies have suggested that a significant proportion of patients with axillary nodal metastases diagnosed by pre-operative axillary ultrasound (AUS)-guided needle biopsy were over-treated with axillary lymph node dissection (ALND). The role of routine AUS and needle biopsy in early breast cancer was questioned. This review aims to determine if pre-operative AUS could predict the extent of axillary tumor burden and need of ALND.

METHODS

PubMed and Embase literature databases were searched systematically for abnormal AUS characteristics and axillary nodal burden. Studies were eligible if they correlated the sonographic abnormalities in AUS with the resultant axillary nodal burden in ALND according to the ACOSOG Z0011 criteria.

RESULTS

Eleven retrospective studies and one prospective study with 1658 patients were included. Sixty-five percent of patients with one abnormal lymph node in AUS and 56% of those with two had low axillary nodal burden. Using one abnormal lymph node as the cut-off, the pooled sensitivity and specificity in prediction of axillary nodal burden were 66% (95%CI 63-69%) and 73% (95% CI 70-76%), respectively. Across the six studies that evaluated suspicious nodal characteristics, increased nodal cortical thickness may be associated with high axillary nodal burden.

CONCLUSION

More than half of the patients with pre-operative positive AUS and biopsy proven axillary nodal metastases were over-treated by ALND. Quantification of suspicious nodes and extent of cortical morphological changes in AUS may help identify suitable patients for sentinel lymph node biopsy.

CNN-Based Approaches with Different Tumor Bounding Options for Lymph Node Status Prediction in Breast DCE-MRI

Simple Summary

Breast cancer represents the most frequent cancer in women in the world. The state of the axillary lymph node is considered an independent prognostic factor and is currently evaluated only with invasive methods. Deep learning approaches, especially the ones based on convolutional neural networks, offer a valid, non-invasive alternative, allowing extraction of large amounts of the quantitative data that are used to build predictive models. The aim of our work is to evaluate the influence of the peritumoral parenchyma through different bounding box techniques on the prediction of the axillary lymph node in breast cancer patients using a deep learning artificial intelligence approach.

Abstract

Background: The axillary lymph node status (ALNS) is one of the most important prognostic factors in breast cancer (BC) patients, and it is currently evaluated by invasive procedures. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), highlights the physiological and morphological characteristics of primary tumor tissue. Deep learning approaches (DL), such as convolutional neural networks (CNNs), are able to autonomously learn the set of features directly from images for a specific task. Materials and Methods: A total of 155 malignant BC lesions evaluated via DCE-MRI were included in the study. For each patient’s clinical data, the tumor histological and MRI characteristics and axillary lymph node status (ALNS) were assessed. LNS was considered to be the final label and dichotomized (LN+ (27 patients) vs. LN− (128 patients)). Based on the concept that peritumoral tissue contains valuable information about tumor aggressiveness, in this work, we analyze the contributions of six different tumor bounding options to predict the LNS using a CNN. These bounding boxes include a single fixed-size box (SFB), a single variable-size box (SVB), a single isotropic-size box (SIB), a single lesion variable-size box (SLVB), a single lesion isotropic-size box (SLIB), and a two-dimensional slice (2DS) option. According to the characteristics of the volumes considered as inputs, three different CNNs were investigated: the SFB-NET (for the SFB), the VB-NET (for the SVB, SIB, SLVB, and SLIB), and the 2DS-NET (for the 2DS). All the experiments were run in 10-fold cross-validation. The performance of each CNN was evaluated in terms of accuracy, sensitivity, specificity, the area under the ROC curve (AUC), and Cohen’s kappa coefficient (K). Results: The best accuracy and AUC are obtained by the 2DS-NET (78.63% and 77.86%, respectively). The 2DS-NET also showed the highest specificity, whilst the highest sensibility was attained by the VB-NET based on the SVB and SIB as bounding options. Conclusion: We have demonstrated that a selective inclusion of the DCE-MRI’s peritumoral tissue increases accuracy in the lymph node status prediction in BC patients using CNNs as a DL approach.

Factors Associated with Axillary Lymph Node Status in Clinically Node-Negative Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy

Adequate axillary lymph node (ALN) staging is critical for patients with invasive breast cancer. However, neoadjuvant chemotherapy (NAC) was associated with a lower risk of ALN metastasis compared with those who underwent primary surgery among clinically node-negative (cN0) patients. This study aimed to investigate the factors associated with ALN status among patients with cN0 breast cancer undergoing NAC. A total of 222 consecutive patients with cN0 breast cancer undergoing NAC between January 2012 and December 2021 were reviewed. Univariate and multivariate analyses were performed to compare factors associated with positive ALN status. Seventeen patients (7.7%) had ALNs metastases. Here, 90 patients (40.5%) achieved pathologic complete response in the breast (breast-pCR), and all had negative ALN status. Lymphovascular invasion (odds ratio: 29.366, p < 0.0001) was an independent risk predictor of ALN metastasis in all study populations. Among patients without breast-pCR, mastectomies were performed more frequently in patients with ALN metastasis (52.9%) than in those without metastasis (20.9%) (p = 0.013). Our findings support the omission of axillary surgery in patients who achieve breast-pCR. Prospective studies are needed to confirm the feasibility of a future two-stage surgical plan for breast-conserving surgery in patients who are likely to achieve breast-pCR during clinical evaluation.

Non-invasive predictors of axillary lymph node burden in breast cancer: a single-institution retrospective analysis

Purpose

Axillary staging is an important prognostic factor in breast cancer. Sentinel lymph node biopsy (SNB) is currently used to stage patients who are clinically and radiologically node-negative. Since the establishment that axillary node clearance (ANC) does not improve overall survival in breast-conserving surgery for patients with low-risk biological cancers, axillary management has become increasingly conservative. This study aims to identify and assess the clinical predictive value of variables that could play a role in the quantification of axillary burden, including the accuracy of quantifying abnormal axillary nodes on ultrasound.

Methods

A retrospective analysis was conducted of hospital data for female breast cancer patients receiving an ANC at our centre between January 2018 and January 2020. The reference standard for axillary burden was surgical histology following SNB and ANC, allowing categorisation of the patients under ‘low axillary burden’ (2 or fewer pathological macrometastases) or ‘high axillary burden’ (> 2). After exploratory univariate analysis, multivariate logistic regression was conducted to determine relationships between the outcome category and candidate predictor variables: patient age at diagnosis, tumour focality, tumour size on ultrasound and number of abnormal lymph nodes on axillary ultrasound.

Results

One hundred and thirty-five patients were included in the analysis. Logistic regression showed that the number of abnormal lymph nodes on axillary ultrasound was the strongest predictor of axillary burden and statistically significant (P = 0.044), with a sensitivity of 66.7% and specificity of 86.8% (P = 0.011).

Conclusion

Identifying the number of abnormal lymph nodes on preoperative ultrasound can help to quantify axillary nodal burden and identify patients with high axillary burden, and should be documented as standard in axillary ultrasound reports of patients with breast cancer.

A nomogram for predicting three or more axillary lymph node involvement before breast cancer surgery

Based on the American College of Surgeons Oncology Group (ACOSOG)-Z0011, a useful nomogram has been constructed to identify patients who do not require intraoperative frozen sections to evaluate sentinel lymph nodes in the previous study. This study investigated the developed nomogram by ultrasonography (US) and positron emission tomography (PET)/computed tomography (CT) as a modality. In the training set, 89/1030 (8.6%) patients had three or more positive nodes. Larger tumor size, higher grade ultrasonographic ALN classification, and findings suspicious of positive ALN on PET/CT were associated in multivariate analysis. The areas under the receiver operating characteristic curve (AUC) of the nomogram were 0.856 [95% CI 0.815-0.897] in the training set. The AUC in the validation set was 0.866 [95% CI 0.799-0.934]. Application of the nomogram to 1067 patients who met the inclusion criteria of ACOSOG-Z0011 showed that 90 (8.4%) patients had scores above the cut-off and a false-negative result was 37 (3.8%) patients. And the specificity was 93.8%, and the negative predictive value was 96.4%. The upgraded nomogram improved the predictive accuracy, using only US and PET/CT. This nomogram is useful for identifying patients who do not require intraoperative analysis of sentinel lymph nodes and considering candidates for identifying neoadjuvant chemotherapy. The patients consisted of clinical T1-2 and node-negative invasive breast cancer. The training and validation set consisted of 1030 and 781 patients, respectively. A nomogram was constructed by analyzing factors related to three or more axillary lymph node metastases. The patients who matched the ACOSOG-Z0011 criteria were selected and applied to the new nomogram.

Role of shear wave elastography as an adjunct to axillary ultrasonography in predicting nodal metastasis in breast cancer patients with suspicious nodes

OBJECTIVE

To evaluate the role of shear wave elastography (SWE) of suspicious axillary lymph nodes and its combination with B-mode USG in predicting nodal metastasis in breast cancer patients.

METHODS

Prospective observational study was performed from June 2018 to August 2020 on breast cancer patients with suspicious axillary nodes on USG. B-mode features (cortical thickness, effacement of fatty hilum, non-hilar blood flow and round shape) and SWE parameters (Emax, Emin, Emean and ESD) of the node with the thickest cortex were evaluated. Diagnostic performances of USG, SWE and their combination were estimated using pathological status of the node on biopsy as the gold standard.

RESULTS

Of the 54 patients evaluated, optimal elasticity maps were obtained in 49 nodes of 49 patients (mean age, 46.3 ± 12.1 years; 48/49 (98%) females). On biopsy, 38 nodes (77.6%) had metastasis, while 11 (22.4%) had reactive hyperplasia. Emax, Emin, Emean and ESD of both cortex and hilum were significantly higher in metastatic than reactive nodes. Emax (cortex) ≥14.9 kPa had the best diagnostic performance (sensitivity, 73.7%; specificity, 81.8%). Cortical thickness ≥6.7 mm had the best diagnostic performance among B-mode features (sensitivity, 89.5%; specificity, 72.7%). Combining cortical thickness with effacement of fatty hilum and/or non-hilar blood flow yielded sensitivity of 89.5% and specificity of 90.9%. Addition of Emax (cortex) to cortical thickness and combination of ≥2 B-mode features increased their specificities to 90.9 and 100%, respectively.

CONCLUSIONS

Metastatic axillary nodes are stiffer than reactive nodes on SWE in breast cancer patients. Emax (cortex) has the best diagnostic performance in differentiating between reactive hyperplasia and nodal metastasis. Combination of Emax (cortex) and cortical thickness increases the specificity for diagnosing metastasis, especially in nodes showing only cortical thickening.

ADVANCES IN KNOWLEDGE

Combination of SWE and B-mode USG is highly specific for differentiating metastasis from reactive hyperplasia in suspicious nodes of breast carcinoma patients, especially in nodes with only cortical thickening.

ACR Appropriateness Criteria® Imaging of the Axilla

This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Axillary Needle Biopsy in the Era of American College of Surgeons Oncology Group (ACOSOG) Z0011: Institutional Experience With a Largely Urban Minority Population and Review of the Literature

Background: The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated that sentinel lymph node biopsy (SLNB) alone is adequate for axillary control in patients with one to two positive axillary lymph nodes. However, axillary lymph node dissection (ALND) is required in patients with N1 disease diagnosed with a preoperative needle biopsy. In this report, we determined how many patients could potentially have had SNB alone based on finding only one to two positive nodes in the axilla.

Methods: A retrospective review of patients with positive preoperative axillary needle biopsy undergoing ALND was used to identify rates of high volume axillary disease (>2 positive nodes). Wilcoxon’s rank-sum and Fisher’s exact test were used for statistical analysis. A review of the literature is included for comparison.

Results: 73% of 51 total patients with a positive needle biopsy had >2 positive nodes on axillary dissection. The high-volume axillary disease was significantly more likely with the presence of lymphovascular invasion and extranodal extension.

Conclusions: Patients with positive preoperative axillary needle biopsies have a significantly higher rate of high volume axillary disease. However, at least one-quarter of these patients will have <3 positive nodes and potentially could have been treated with SNB alone.

Development of High-Resolution Dedicated PET-Based Radiomics Machine Learning Model to Predict Axillary Lymph Node Status in Early-Stage Breast Cancer

Simple Summary

Accurate clinical axillary evaluation plays an important role in the diagnosis of and treatment planning for breast cancer (BC). This study aimed to develop a machine learning model integrating dedicated breast PET and clinical characteristics for prediction of axillary lymph node status in cT1-2N0-1M0 BC non-invasively. The performance of this integrating model in identifying pN0 and pN1 with the AUC was 0.94. We achieved an NPV of 96.88% in the cN0 and PPV of 92.73% in the cN1 subgroup. The higher true positive and true negative rate could delineate clinical subtypes and apply more precise treatment for patients with early-stage BC.

Abstract

Purpose of the Report: Accurate clinical axillary evaluation plays an important role in the diagnosis and treatment planning for early-stage breast cancer (BC). This study aimed to develop a scalable, non-invasive and robust machine learning model for predicting of the pathological node status using dedicated-PET integrating the clinical characteristics in early-stage BC. Materials and Methods: A total of 420 BC patients confirmed by postoperative pathology were retrospectively analyzed. 18F-fluorodeoxyglucose (¹⁸F-FDG) Mammi-PET, ultrasound, physical examination, Lymph-PET, and clinical characteristics were analyzed. The least absolute shrinkage and selection operator (LASSO) regression analysis were used in developing prediction models. The characteristic curve (ROC) of the area under receiver-operator (AUC) and DeLong test were used to evaluate and compare the performance of the models. The clinical utility of the models was determined via decision curve analysis (DCA). Then, a nomogram was developed based on the model with the best predictive efficiency and clinical utility and was validated using the calibration plots. Results: A total of 290 patients were enrolled in this study. The AUC of the integrated model diagnosed performance was 0.94 (95% confidence interval (CI), 0.91–0.97) in the training set (n = 203) and 0.93 (95% CI, 0.88–0.99) in the validation set (n = 87) (both p < 0.05). In clinical N0 subgroup, the negative predictive value reached 96.88%, and in clinical N1 subgroup, the positive predictive value reached 92.73%. Conclusions: The use of a machine learning integrated model can greatly improve the true positive and true negative rate of identifying clinical axillary lymph node status in early-stage BC.

Prognostic value and management of regional lymph nodes in locoregional breast cancer recurrence: a systematic review of the literature

PURPOSE

Management of regional lymph nodes in breast cancer recurrence has been heterogeneous. To facilitate clinical practice, this review aims to give an overview on the prognosis, staging and operative management of (inapparent) regional lymph nodes.

METHODS

Current national and international guidelines are reviewed and a structured search of the literature between Jan 1, 1999 and Feb 1, 2021 on the repeat sentinel node biopsy (re-SNB) procedure was performed.

RESULTS

Positive regional lymph nodes in recurrent breast cancer indicate a poorer outcome with axillary recurrences being the most favorable tumor site among all nodal regions. Most preferred staging method is ultrasound ± guided biopsy. PET-CT, scintimammography, SPECT-CT may improve visualization of affected lymph nodes outside the axilla. Concerning operative management 30 articles on re-SNB were identified with a mean harvesting rate of 66.4%, aberrant drainage and aberrant metastasis in 1/3 of the cases. Total rate of metastasis is 17.9%. After previous axillary dissection (ALND) the re-SNB has a significantly lower harvesting rate and higher aberrant drainage and aberrant metastasis rate. The prognostic outcome after re-SNB has been favorable.

CONCLUSION

Nodal status in recurrent disease has prognostic value. The choice of operative management of clinically inapparent regional lymph nodes during local recurrence should be based on the previous nodal staging method. Patients with previous ALND should be spared a second systematic ALND. Re-SNB or no axillary surgery at all are possible alternatives. Lymphoscintigraphy may be performed to identify extraaxillary drainage. However, for definite recommendations randomized controlled studies are heavily needed.

Diagnostic performance of a novel high-resolution dedicated axillary PET system in the assessment of regional nodal spread of disease in early breast cancer

Background

In early breast cancer, a non-invasive method with higher sensitivity and negative predictive value (NPV) is needed to identify and recognize more indolent axillary lymph nodes (ALNs). This study aimed to assess whether a novel high-resolution dedicated ALN positron emission tomography (LymphPET) system could improve sensitivity in detecting early breast cancer (clinical N0-N1 stage).

Methods

A total of 103 patients with clinical stage T1-2N0-1M0 breast cancer were evaluated by ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) LymphPET. The maximum single-voxel PET uptake value of ALNs (maxLUV) and the tumor-to-background ratio (TBR) for fat (TBR1) and muscle (TBR2) tissue were calculated. Then, 78 patients with cN0 stage breast cancer received sentinel lymph node biopsy alone or combined with axillary lymph node dissection (ALND), and 25 patients with cN1 stage breast cancer underwent fine-needle aspiration.

Results

A total of 99 invasive breast carcinoma cases were included in this study. The diagnostic sensitivity of LymphPET was 88%, specificity was 79%, false-negative rate was 12%, the false-positive rate was 21%, positive predictive value was 75%, NPV was 90%, and accuracy was 83%. The maxLUV was superior to TBR1 and TBR2 in detecting ALNs, with 0.27 being the most optimal cutoff value.

Conclusions

The ¹⁸F-FDG LymphPET system can be used to identify and recognize more indolent ALNs of breast cancer due to greater sensitivity and a much higher NPV.

Prediction of Axillary Lymph Node Metastasis in Breast Cancer using Intra-peritumoral Textural Transition Analysis based on Dynamic Contrast-enhanced Magnetic Resonance Imaging

RATIONALE AND OBJECTIVES

Intra-peritumoural textural transition (Ipris) is a new radiomics method, which includes a series of quantitative measurements of the image features that represent the differences between the inside and outside of the tumour. This study aimed to explore the feasibility of Ipris analysis for the preoperative prediction of axillary lymph node (ALN) status in patients with breast cancer based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

MATERIALS AND METHODS

This study was approved by the Institutional Review Board (IRB) of our hospital. One hundred sixty-six patients with clinicopathologically confirmed invasive breast cancer and ALN status were enrolled. All patients underwent preoperative breast DCE-MRI examinations. The primary breast lesion was manually segmented using the ITK-SNAP software for each patient. Two sets of image features were extracted, including Ipris features and conventional intratumoural features. Feature selection was conducted using Spearman correlation analysis and support vector machine with recursive feature elimination (SVM-RFE). Next, three models were established in training dataset: Model 1 was established by Ipris features; Model 2 was established by intratumoural features; Model 3 was established by combining Ipris features and intratumoural features. The performances of the three models were evaluated for the prediction of ALN status in testing datasets.

RESULTS

Model 1 with four Ipris features achieved an AUC of 0.816 (95% CI, 0.733-0.883) and 0.829 (95% CI, 0.695-0.922) in the training and testing datasets, respectively. Model 2 with six intratumoural features achieved an AUC of 0.801 (95% CI, 0.716-0.870) and 0.824 (95% CI, 0.689-0.918) in the training and testing datasets, respectively. By incorporating the Ipris and intratumoural features, the AUC of Model 3 increased to 0.968 (95% CI, 0.916-0.992) and 0.855 (95% CI, 0.724-0.939) in the training and testing datasets, respectively.

CONCLUSION

Ipris features based on DCE-MRI can be used to predict ALN status in patients with breast cancer. The model combining intratumoural and Ipris features achieved higher prediction performance.

Axillary Imaging Following a New Invasive Breast Cancer Diagnosis-A Radiologist's Dilemma

Traditionally, patients with newly diagnosed invasive breast cancer underwent axillary US to assess for suspicious axillary lymph nodes (LNs), which were then targeted for image-guided needle biopsy to determine the presence of metastasis. Over the past decade, there has been a shift towards axillary preservation. For patients with palpable lymphadenopathy, the decision to perform axillary imaging with documentation of the number and location of abnormal LNs in preparation for image-guided LN sampling is straightforward. Since LN involvement correlates with cancer size, it is reasonable to image the axilla in patients with tumors larger than 5 cm; however, for tumors smaller than 5 cm, axillary imaging is often deferred until after the tumor molecular subtype and treatment plan are established. Over the last decade, neoadjuvant chemotherapy (NACT) is increasingly used for smaller cancers with more aggressive molecular subtypes. In most cases, detecting axillary metastasis is critical when deciding whether the patient would benefit from NACT. There is increasing evidence that abnormal axillary US findings correlates with LN metastases and reliably establishes a baseline to monitor response to NACT. Depending on hormone receptor status, practices may choose to image the axilla in the setting of clinical stage T1 and T2 cancers to evaluate nodal status and help determine further steps in care. Radiologists should understand the nuances of axillary management and the scope and challenges of LN marking techniques that significantly increase the precision of limited axillary surgery.

To Look or Not to Look? Axillary Imaging: Less May Be More

Axillary lymph node status in patients with breast cancer is an important prognostic indicator and often guides vital treatment decisions. Although in many cases imaging plays a crucial role in the assessment of the axilla, it is essential that targeted axillary US and/or image-guided biopsy of an axillary lymph node be performed by the radiologist only when clinically appropriate. This decision-making process requires multidisciplinary communication and collaboration among radiologists, surgeons, medical oncologists, and radiation oncologists. Our goal is to review axillary imaging for patients with breast cancer in two distinct clinical settings, the patient with newly diagnosed breast cancer who meets American College of Surgeons Oncology Group Z0011 criteria and patients undergoing neoadjuvant chemotherapy, with a specific focus on potential reasons to not perform axillary US and/or image-guided biopsy in these settings.

Imaging Evaluation of the Axilla-A National Survey of Clinical Practice Among Radiologists

OBJECTIVE

To assess awareness and implementation of the American College of Surgeons Oncology Group Z0011 trial findings, approaches to axillary nodal imaging, and to identify differences in practice based on respondent characteristics.

METHODS

An online survey was distributed to members of the Society of Breast Imaging. Questions regarded demographics, evaluation approaches, and impact of the Z0011 trial. Poisson regression with robust standard errors to regression was used to generate multivariable-adjusted relative risks and 95% confidence intervals (CIs) for associations.

RESULTS

The response rate was 21.7% (430/2007). The majority (295/430, 68.6%) reported always performing axillary US in patients with a BI-RADS 4B, 4C, or 5 breast mass. Most respondents (299/430, 69.5%) were familiar with the findings of the Z0011 trial. Radiologists in academic practice were 0.67 (95% CI: 0.54-0.83) times less likely than private practice radiologists to perform axillary US in all masses and 1.31 (95% CI: 1.13-1.52) times more likely to be very familiar with the trial. Frequency of axillary US showed no association with time spent in breast imaging, years in practice, or presence of dedicated breast surgeons. Increased time in breast imaging and presence of dedicated breast surgeons was strongly associated with familiarity with the trial. No association was observed with years in practice. Most respondents (291/430, 67.7%) made little or no change to their practice based on trial findings.

CONCLUSION

There is wide variability in approaches to axillary nodal evaluation, demonstrating a need for improved education and guidelines for axillary imaging in breast cancer patients.

Vulvar cancer staging: guidelines of the European Society of Urogenital Radiology (ESUR)

Objective

The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging staging guidelines for vulvar cancer and to propose standardised MRI protocols and reporting.

Methods

The guidelines recommended from the ESUR in this article resulted from a questionnaire analysis regarding imaging staging of vulvar cancer that was answered by all members of the Female Pelvic Imaging Working Group. Only the answers with an agreement equal to or more than 80% were considered. Additionally, the literature was reviewed to complement and further support our conclusions.

Results

The critical review of the literature and consensus obtained among experts allows for recommendations regarding imaging staging guidelines, patient preparation, MRI protocol, and a structured MRI report.

Conclusions

Standardising image acquisition techniques and MRI interpretation reduces ambiguity and ultimately improves the contribution of radiology to the staging and management of patients with vulvar cancer. Moreover, structured reporting assists with the communication of clinically relevant information to the referring physician.

Imaging Updates to Breast Cancer Lymph Node Management

Metastatic lymph node involvement in breast cancer is a key determinant of the overall stage of disease and prognosis. Historically, lymph node status was determined by surgery first, with adjuvant treatments determined based on the results of the final surgical pathologic analysis. While this sequence is still applicable in many cases, neoadjuvant systemic treatment (NST) is increasingly being administered as the initial treatment. In cases that demonstrate good therapeutic response to drug therapies, NST may permit the option to perform less radical surgeries subsequently. Current breast cancer treatment has become multidisciplinary, with overlapping roles from the different disciplines. As surgery may be postponed, imaging and image-guided lymph node interventions have gained importance as the primary means of lymph node assessment. Imaging enables evaluation of all regional nodal basins, including locations where surgery is not usually performed. By differentiating limited versus extensive nodal involvement, imaging findings help determine whether initial treatment should be surgical or medical. If medical treatment with NST is indicated, imaging is performed to monitor the in vivo nodal response to drug therapy and ultimately to help determine the surgical technique to perform on the basis of the final imaging findings after NST. The authors discuss the imaging features of nodal metastases and the indications and techniques for the various image-guided procedures. The relative usefulness and shortcomings of the various imaging examinations are reviewed to discuss how they can be applied when biopsy results are not available. The role of imaging in the multidisciplinary team approach is emphasized based on past clinical trials of lymph node management and recent evolving knowledge of breast cancer staging. Online supplemental material is available for this article. ^©RSNA, 2021.

Magnetic-Guided Axillary UltraSound (MagUS) Sentinel Lymph Node Biopsy and Mapping in Patients with Early Breast Cancer. A Phase 2, Single-Arm Prospective Clinical Trial

Lymph Node Dissection (SLND) is standard of care for diagnosing sentinel lymph node (SLN) status in patients with early breast cancer. Study aim was to determine whether the combination of Superparamagnetic iron oxide nanoparticles (SPIO) MRI-lymphography (MRI-LG) and a Magnetic-guided Axillary UltraSound (MagUS) with biopsy can allow for minimally invasive, axillary evaluation to de-escalate surgery. Patients were injected with 2 mL of SPIO and underwent MRI-LG for SN mapping. Thereafter MagUS and core needle biopsy (CNB) were performed. Patients planned for neoadjuvant treatment, the SLN was clipped and SLND was performed after neoadjuvant with the addition of isotope. During surgery, SLNs were controlled for signs of previous biopsy or clip. The primary endpoint was MagUS SLN detection rate, defined as successful SLN detection of at least one SLN of those retrieved in SLND. In 79 patients, 48 underwent upfront surgery, 12 received neoadjuvant and 19 had recurrent cancer. MagUS traced the SLN in all upfront and neoadjuvant cases, detecting all patients with macrometastases (n = 10). MagUS missed only one micrometastasis, outperforming baseline axillary ultrasound AUS (AUC: 0.950 vs. 0.508, p < 0.001) and showing no discordance to SLND (p = 1.000). MagUS provides the niche for minimally invasive axillary mapping that can reduce diagnostic surgery.

Breast Cancer Skip Metastases: Frequency, Associated Tumor Characteristics, and Role of Staging Nodal Ultrasound in Detection

BACKGROUND. Staging nodal ultrasound (US) evaluates locations beyond those assessed during routine surgical dissection and has an increasing role in breast cancer management given the growing use of neoadjuvant systemic therapy before surgical staging. OBJECTIVE. The purpose of this study is to identify the patterns of nodal spread of breast cancer observed at staging nodal US and to determine the frequency of skip metastases and associated tumor characteristics. METHODS. This retrospective study included 1269 consecutive patients (31 with bilateral synchronous cancers) who had 1300 newly diagnosed, untreated, invasive breast cancers and underwent US examination of the ipsilateral regional nodal basins from January 2016 through March 2017. Cases with suspicious nodes on US underwent fine-needle aspiration (FNA) biopsy. Cases with benign results on FNA and no suspicious nodes on US underwent sentinel lymph node biopsy. Results of US with FNA were compared with final surgical pathology. Skip metastases were defined as spread across discontiguous nodal levels or distant metastases in the absence of ipsilateral nodal metastases. The incidence and patterns of spread of skip metastases were summarized; associations with tumor characteristics were tested using the Fisher exact test. RESULTS. A total of 591 metastatic cases (45.5%) were confirmed by needle biopsy or sentinel lymph node biopsy, comprising 463 nodal metastases (N+) confirmed by FNA, 121 nodal metastases (N+) confirmed by sentinel lymph node biopsy, and seven distant organ metastases without nodal metastases (N0M1) confirmed by CT-guided biopsy. US with FNA had sensitivity of 86.0%, specificity of 100.0%, PPV of 100.0%, NPV of 89.5%, and accuracy of 93.6%. There were 34 skip metastases, for an incidence of 2.6% (34/1300) (95% CI, 1.8-3.6%) among all invasive cancers and 7.2% (34/470) (95% CI, 5.1-9.9%) among metastatic cancers detected by US and FNA. Skip metastases occurred to axillary level III (n = 4), the supraclavicular nodal basin (n = 21), the contralateral axilla (n = 2), and distant organs (n = 7). Cancers with skip metastases, compared with those with nonskip metastases, had higher rates (p = .005) of lobular histology (23.5% vs 6.7%) and mixed ductal and lobular histology (11.8% vs 6.7%). Skip metastases were not associated with grade, T category, or molecular subtype (p > .05). CONCLUSION. Skip metastases to locations beyond standard surgical axillary dissection occur in 7.2% of metastatic breast cancers. CLINICAL IMPACT. Staging nodal US identifies skip metastases that otherwise would be undetected, helping to achieve more accurate staging and minimize undertreatment.

Management of the Axilla in Early-Stage Breast Cancer: Ontario Health (Cancer Care Ontario) and ASCO Guideline

PURPOSE

To provide recommendations on the best strategies for the management and on the best timing and treatment (surgical and radiotherapeutic) of the axilla for patients with early-stage breast cancer.

METHODS

Ontario Health (Cancer Care Ontario) and ASCO convened a Working Group and Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature.

RESULTS

This guideline endorsed two recommendations of the ASCO 2017 guideline for the use of sentinel lymph node biopsy in patients with early-stage breast cancer and expanded on that guideline with recommendations for radiotherapy interventions, timing of staging after neoadjuvant chemotherapy (NAC), and mapping modalities. Overall, the ASCO 2017 guideline, seven high-quality systematic reviews, 54 unique studies, and 65 corollary trials formed the evidentiary basis of this guideline.

RECOMMENDATIONS

Recommendations are issued for each of the objectives of this guideline: (1) To determine which patients with early-stage breast cancer require axillary staging, (2) to determine whether any further axillary treatment is indicated for women with early-stage breast cancer who did not receive NAC and are sentinel lymph node-negative at diagnosis, (3) to determine which axillary strategy is indicated for women with early-stage breast cancer who did not receive NAC and are pathologically sentinel lymph node-positive at diagnosis (after a clinically node-negative presentation), (4) to determine what axillary treatment is indicated and what the best timing of axillary treatment for women with early-stage breast cancer is when NAC is used, and (5) to determine which are the best methods for identifying sentinel nodes.Additional information is available at www.asco.org/breast-cancer-guidelines.

PET/MRI for Staging the Axilla in Breast Cancer: Current Evidence and the Rationale for SNB vs. PET/MRI Trials

Simple Summary

PET/MRI is a relatively new, hybrid imaging tool that allows practitioners to obtain both a local and systemic staging in breast cancer patients in a single exam. To date, the available evidence is not sufficient to determine the role of PET/MRI in breast cancer management. The aims of this paper are to provide an overview of the current literature on PET/MRI in breast cancer, and to illustrate two ongoing trials aimed at defining the eventual role of PET/MRI in axillary staging in two different settings: patients with early breast cancer and patients with positive axillary nodes that are candidates for primary systemic therapy. In both cases, findings from PET/MRI will be compared with the final pathology and could be helpful to better tailor axillary surgery in the future.

Abstract

Axillary surgery in breast cancer (BC) is no longer a therapeutic procedure but has become a purely staging procedure. The progressive improvement in imaging techniques has paved the way to the hypothesis that prognostic information on nodal status deriving from surgery could be obtained with an accurate diagnostic exam. Positron emission tomography/magnetic resonance imaging (PET/MRI) is a relatively new imaging tool and its role in breast cancer patients is still under investigation. We reviewed the available literature on PET/MRI in BC patients. This overview showed that PET/MRI yields a high diagnostic performance for the primary tumor and distant lesions of liver, brain and bone. In particular, the results of PET/MRI in staging the axilla are promising. This provided the rationale for two prospective comparative trials between axillary surgery and PET/MRI that could lead to a further de-escalation of surgical treatment of BC. • SNB vs. PET/MRI 1 trial compares PET/MRI and axillary surgery in staging the axilla of BC patients undergoing primary systemic therapy (PST). • SNB vs. PET/MRI 2 trial compares PET/MRI and sentinel node biopsy (SNB) in staging the axilla of early BC patients who are candidates for upfront surgery. Finally, these ongoing studies will help clarify the role of PET/MRI in BC and establish whether it represents a useful diagnostic tool that could guide, or ideally replace, axillary surgery in the future.

The combination of contrast-enhanced ultrasonography with blue dye for sentinel lymph node detection in clinically negative node breast cancer

PURPOSE

The aim of this prospective study was to evaluate the value of the combination of contrast-enhanced ultrasonography (CEUS) and blue dye (BD) for SLN detection in patients with clinically negative node breast cancer.

METHODS

Patients with clinically negative node breast cancer were randomized into two cohorts for SLN biopsy (SLNB): the combination method cohort using CEUS and BD together, and the single BD method cohort. Standard axillary lymph node dissection was performed if any of the SLNs confirmed positive by pathology. The identification rate, the number of SLNs removed and recurrence-free survival (RFS) rates were evaluated between two cohorts. In addition, we assessed the sensitivity, specificity, accuracy, false-negative rate of CEUS for diagnosis of SLNs based on patterns of CEUS enhancement.

RESULTS

144 consecutive patients with clinically negative node breast cancer were randomized into two cohorts. Each cohort consisted of 72 cases. In the combination method cohort, contrast-enhanced lymphatic vessels were clearly visualized and SLNs were accurately localized in 72 cases. The identification rate and the mean number of SLNs detected by the combination method were 100% (72/72) and 3.26 (1-9), respectively. In contrast, in the single BD method cohort, SLNs in 69 cases were successfully identified. The identification rate and the mean number of SLNs using BD alone were 95.8% (69/72) and 2.21 (1-4), respectively. According to patterns of CEUS enhancement, the sensitivity, specificity, accuracy, and the FNR of CEUS for SLN diagnosis were 69.2%, 96.6%, 91.7%, and 30.8%, respectively. After a median follow-up of 50 months for the combination method cohort and 51 months for the blue dye alone cohort, five patients in the combination method cohort and nine in the blue dye alone cohort had recurrence. RFS rates showed no significant difference (P = 0.26) between two cohorts.

CONCLUSION

The combination of CEUS and BD is more effective than BD alone for SLNB in clinically negative node patients with an identification rate as high as 100%. Use of BD and CEUS in combination may provide the possibility of a non-radioactive alternative method for SLNB in centers without access to radioisotope.

Usefulness and Prospects of Sentinel Lymph Node Biopsy for Patients With Breast Cancer Using the Medical Imaging Projection System

Background

The Medical Imaging Projection System (MIPS) projects indocyanine green (ICG) fluorescence images directly on the surgical field using a projection mapping technique. We conducted an observational study of sentinel lymph node (SLN) biopsy using the prototype MIPS; we found a high identification rate. However, the number of SLN-positive cases was small, and the sensitivity could not be evaluated. The aim of this study was to investigate the clinical usefulness of the MIPS assisted ICG fluorescence method using commercially available equipment.

Methods

This was a retrospective observational study. Patients with primary breast cancer who underwent SLN biopsy using the MIPS at Kyoto University Hospital from April to December 2020 were included in the study. The primary endpoints were the identification rate of SLNs and detection of positive SLNs by the MIPS. The secondary endpoint was the number of SLNs excised using the MIPS per patient. We also conducted a questionnaire survey focused on the utility of the MIPS; it involved doctors with an experience in using the MIPS.

Results

Seventy-nine patients (84 procedures) were included in the study. In 60 (71%) procedures, both the radioisotope (RI) method and MIPS were used. At least one SLN could be detected by the MIPS in all the procedures, with an identification rate of 100% (95% confidence interval 95.6–100%). A total of 19 (7%) positive SLNs were removed, which were identifiable by the MIPS. Among 57 patients in whom the MIPS and RI methods were used, there was no positive SLN only identified by the RI method. The results of the questionnaire survey showed that the MIPS enabled the operator and assistant to share the ICG fluorescence image in the surgical field and to communicate with each other easily.

Conclusion

The current study demonstrated that the identification rate of SLNs using the MIPS was high, and the MIPS can be used for detecting positive SLNs. It was suggested that the MIPS will be useful in learning SLN biopsy procedures.

Staging of the Axilla in Breast Cancer and the Evolving Role of Axillary Ultrasound

Axillary lymph nodes have long been recognized as a route for breast cancer to spread systemically. As a result, staging of the axilla has always played a central role in the treatment of breast cancer. Anatomic staging was believed to be important for two reasons: 1) it predicts prognosis and guides medical therapy, and 2) it is a potential therapy for removal of disease in the axilla. This paradigm has now been called into question. Prognostic information is driven increasingly by tumor biology, and trials such as the ACOSOG Z0011 demonstrates removal of axillary disease is not therapeutic. Staging of the axilla has undergone a dramatic de-escalation; however, sentinel lymph node biopsy (SLNB) is still an invasive surgery and represents a large economic burden on the healthcare system. In this review, we outline the changing paradigms of axillary staging in breast cancer from emphasis on anatomic staging to tumor biology, and the evolving role of axillary ultrasound, bringing patients less invasive and more personalized therapy.

Specimen number based diagnostic yields of suspicious axillary lymph nodes in core biopsy in breast cancer: clinical implications from a prospective exploratory study

Background

Ultrasound (US)-guided core needle biopsy (CNB) is widely applied in the pathological diagnosis of suspicious axillary lymph nodes (ALNs) in breast cancer. However, the number of specimens removed during biopsy is currently based on the preference of the individual radiologist. This study aims to analyze the specimen number based diagnostic yields of US guided CNB of suspicious ALNs in breast cancer.

Methods

Core biopsy specimens of suspicious lymph nodes were prospectively obtained from breast cancer patients treated at our hospital between November, 2018, and July, 2019. Four specimens were obtained from each patient and labeled 1-4 in the order they were removed. Each specimen underwent pathological evaluation to determine whether metastasis had occurred. The diagnostic yields of the specimens were calculated and differences in diagnostic accuracy according to the number of specimens were evaluated by McNemar's test.

Results

A total of 167 patients were enrolled, and 139 (83.2%) cases were identified as metastasis by CNB. The diagnostic yields were: 74.2% (specimen 1), 87.8% (specimens 1-2), 91.2% (specimens 1-3), and 94.6% (specimens 1-4). The increases in diagnostic yield from specimen 1 to 1-2 and from specimens 1-2 to 1-4 were significant; however, no significant differences were detected between specimens 1-3 and the first two, or between specimens 1-4 and the first three in this sample size. The lower diagnostic abilities for the first two specimens were associated with shorter long- and short-axis lengths of lymph nodes on US.

Conclusions

Although the second specimen contributed significant diagnostic yield of suspicious axillary lymph nodes in core biopsy in breast cancer, a minimum number cannot be determined by this study. Additional specimens may improve diagnostic yield particularly in patients with small nodes.

Breast cancer: comparison of quantitative dual-layer spectral CT and axillary ultrasonography for preoperative diagnosis of metastatic axillary lymph nodes

Background

Our aim was to compare the diagnostic performance of quantitative dual-layer spectral computed tomography (DLSCT) and axillary ultrasound (US) for diagnosing lymph node metastases in breast cancer patients.

Methods

DLSCT and axillary US were prospectively performed in 70 needle biopsy-verified breast cancer patients. Histopathology and imaging data were available for evaluation in 36 axillae from 34 patients. In each patient, ipsilateral, contralateral, and inguinal lymph nodes (LNs) were semiautomatically segmented, and iodine density, spectral slope, Z effective, virtual non-contrast (VNC), conventional CT HU values, and Δ contrast enhancement (ΔCE, conventional CT HU minus VNC) were measured. Using histopathology as reference, the diagnostic performance of DLSCT and axillary US was compared.

Results

Of 36 axillae, 23 had metastatic lymph nodes. Compared with non-metastatic LNs, metastatic LNs had significantly different iodine density (p = 0.021), spectral slope (p < 0.001), Z effective (p < 0.001), conventional CT HU values (p < 0.01), and ΔCE (p < 0.01). All DLSCT parameters were significantly different between arterial phase and portal-venous phase (p < 0.001) except for VNC (p = 0.092). ΔCE had the highest diagnostic performance (sensitivity 0.79, specificity 0.92, positive predictive value 0.95, negative predictive value 0.69) with a significantly increased sensitivity compared with conventional CT HU (p = 0.027). There were no significant differences between ΔCE and axillary US for sensitivity (p = 1.000) or specificity (p = 0.320).

Conclusions

DLSCT is a promising quantitative technique for evaluating LN metastases and could potentially reduce the need for sentinel LN biopsy.

Pretherapeutic Imaging for Axillary Staging in Breast Cancer: A Systematic Review and Meta-Analysis of Ultrasound, MRI and FDG PET

BACKGROUND

This systematic review aimed at comparing performances of ultrasonography (US), magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography (PET) for axillary staging, with a focus on micro- or micrometastases.

METHODS

A search for relevant studies published between January 2002 and March 2018 was conducted in MEDLINE database. Study quality was assessed using the QUality Assessment of Diagnostic Accuracy Studies checklist. Sensitivity and specificity were meta-analyzed using a bivariate random effects approach; Results: Across 62 studies (n = 10,374 patients), sensitivity and specificity to detect metastatic ALN were, respectively, 51% (95% CI: 43-59%) and 100% (95% CI: 99-100%) for US, 83% (95% CI: 72-91%) and 85% (95% CI: 72-92%) for MRI, and 49% (95% CI: 39-59%) and 94% (95% CI: 91-96%) for PET. Interestingly, US detects a significant proportion of macrometastases (false negative rate was 0.28 (0.22, 0.34) for more than 2 metastatic ALN and 0.96 (0.86, 0.99) for micrometastases). In contrast, PET tends to detect a significant proportion of micrometastases (true positive rate = 0.41 (0.29, 0.54)). Data are not available for MRI.

CONCLUSIONS

In comparison with MRI and PET Fluorodeoxyglucose (FDG), US is an effective technique for axillary triage, especially to detect high metastatic burden without upstaging majority of micrometastases.

Extra-axillary nodal metastases in breast cancer: comparison of ultrasound, MRI, PET/CT, and CT

PURPOSE

To evaluate how ultrasound (US), MRI, PET/CT, and CT predict extra-axillary nodal metastases.

SUBJECTS AND METHODS

This IRB approved, retrospective study consisted of 124 suspicious supraclavicular and 88 internal mammary (IM) nodal cases with US and at least one additional cross-sectional examination (MRI, PET/CT or CT) from a total of 1472 invasive cancers with staging nodal US between January 2016-January 2019. Imaging findings were compared with the true node status, determined by fine needle aspirate (FNA) biopsy or evidence of response to chemotherapy on follow up imaging.

RESULTS

In the supraclavicular region, US had accuracy 98.2%, consisting of 97 true positives (TP), 27 false positives (FP), and 1348 true negative (TN). 93.5% of suspicious supraclavicular nodes had FNA for a PPV 78.2%. PET/CT had accuracy 88.6% (26 TP, 5 TN and 4 false negatives (FN)). CT exams had accuracy 61.7% (42 TP, 16 TN, 7 FP, and 29 FN). In the IM region, US had accuracy 93.2% (82 TP, 1 FP, 5 FN, and 1384 TN) but only 43.2% of suspicious IM nodes had FNA for a PPV 98.8%. MRI had accuracy 100.0% (all 47 TP). PET/CT exams had accuracy 96.8% (30 TP and 1FN). CT exams had accuracy 62.7% (36 TP, 1 TN, and 22 FN).

CONCLUSION

US/FNA has accuracy 98.2% and 93.2% in the supraclavicular and IM regions, however only 43.2% of suspicious IM nodes are directly sampled. In these cases, MRI or PET/CT can be used to problem solve and guide treatment decisions.

Can We Avoid Axillary Lymph Node Dissection (ALND) in Patients with 1-2 Positive Sentinel/Low Axillary Lymph Nodes (SLN/LAS+) in the Indian Setting?

The ACOSOG Z0011 study, heralded as a "practice changing" trial, suggested that women with T1-2 breast cancer with 1-2 SLN+, undergoing breast conservation therapy, need not be offered further ALND. However, whether these results are applicable to all women in the Indian setting, it remains debatable. A retrospective audit of all cN0 operated from 2013 to 2018 was conducted. We analyzed the percentage of additional LN positive (LN+) in the ALND group and compared it to the ACOZOG Z11 trial. Of the 2350 cN0 with EBC who underwent LAS, 687 (29%) had positive lymph nodes on final histopathology. Five hundred ninety-seven (86.9%) patients had 1-2 LN+, 40 (5.8%) patients had 3 LN+, and 50 (7.3%) had 4 or more nodes positive. Demographic features in the ACOSOG Z11 are different from those in our study, looking at ACOZOG Z11 versus our cohort-median pT 1.7 cm versus 3 cm, 45% micrometastasis versus 99.16% macrometastasis, and 28-30% grade 3 tumors versus 73.7%. In our cohort 31.82% of the 1-2 LN positive had additional LN+ on ALND. Keeping in mind the difference in clinicopathological features between our cohort and that of ACOZOG Z0011 and that 31.82% of women had additional LN+ on ALND, it may not be appropriate to apply the results of the ACOSOG Z0011 trial directly to our general population. Possibly, only a select subset of patients who match the trial population of the ACOSOG Z11 could be offered observation of the axilla and validated nomograms can be used to identify high-risk patients.